Provider Demographics
NPI:1851945042
Name:GORDON, JUSTINE AMBER (NONE)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:AMBER
Last Name:GORDON
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3171 W OLYMPIC BLVD # 114
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4760 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4820
Practice Address - Country:US
Practice Address - Phone:415-652-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2021-10-28
Deactivation Date:2021-10-22
Deactivation Code:
Reactivation Date:2021-10-28
Provider Licenses
StateLicense IDTaxonomies
CAAMFT126587101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health